Provider Demographics
NPI:1225567704
Name:LADERA PARK DERMATOLOGY PA
Entity Type:Organization
Organization Name:LADERA PARK DERMATOLOGY PA
Other - Org Name:LAKE TRAVIS DERMATOLOGY PA
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ADRIENNE
Authorized Official - Middle Name:M
Authorized Official - Last Name:FEASEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:512-345-3599
Mailing Address - Street 1:11671 JOLLYVILLE RD STE 104
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759-4141
Mailing Address - Country:US
Mailing Address - Phone:512-345-3599
Mailing Address - Fax:512-345-3928
Practice Address - Street 1:11671 JOLLYVILLE RD STE 104
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78759-4141
Practice Address - Country:US
Practice Address - Phone:512-345-3599
Practice Address - Fax:512-345-3928
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL2883207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty